Micro-Needling Informed Consent Client Name:

Skin Needling Consent Form

1. No guarantee can be given to me as to the condition of my skin or degree of improvement expected following my procedure(s It is recommended that up to 3 treatments may be needed to obtain desired results.

2. I understand that multiple treatments may be needed and the use of home care products is recommended to achieve optimal results. I understand that I must follow the aftercare instructions given to me by my technician. (If applicable)

3. I am not pregnant, lactating, or trying to get pregnant. (If applicable)

4. If outdoors, I will apply broad spectrum sunscreen with SPF-30 or higher, 30 minutes prior to sun exposure and wear daily until areas treated have healed. This is after the treated areas have healed 100% 3-6 months.

5. In rare cases, allergies or sensitivities have been reported to products used during treatments (topical numbing

6. I understand that the following are contra-indications (should not be used) for the use of Medical Needling:

Infected skin disorder, open cuts, wounds, abrasions

Patients with cardiovascular disease must have doctor's consent

A pacemaker is a direct contra-indication Highly anxious patient Epileptic - electrical currents may precipitate an attack Pregnancy - electrical currents may precipitate labor

Untreated sinusitis - can cause pain in sinus area

Diabetes - consent from physician required If currently taking blood thinners

If there is a history of Shingles

7. I understand that the following possible side effects and/or risk could occur:

Most people heal without any problem. However, here are some problems that you may encounter; If you are prone to fever blisters (herpes simplex) then it is recommended to get a prescription for an anti-viral such as: Zovirax, Acyclovir, or equivalent to take prior to your treatment. This is REQUIRED. You may notice small white dots appearing on the skin. These might be simple little reaction cysts (Milia) or they could be minute infected areas. Carefully, but firmly wipe them away and apply an antibiotic lotion. It is a good idea to consult your doctor about this. Do not allow the white dots to remain on the skin, and if you are not able to remove them yourself then please let the technician know. If the skin becomes painful and more red, then you may have developed an infection and you must see your physician at once. In most cases, redness will begin to subside within 2-4 days, some cases may take longer if a more aggressive treatment is performed. Pinkness may take up to one month to fade. This is not

8. A Non-Comedogenic (not to clog pores) moisturizer such as Cetaphil, is recommended to keep on the areas for the first 1-7 days to help expedite healing and comfort. Keep the treated areas clean. You can wash with a gentle cleanser as often as needed then re-apply moisturizer. Avoid retinols for 10 days after the procedure.

9. I understand that the treated area can remain pink for up to 1 month or sometimes longer and will gradually lighten with time. (Each patient will heal differently No sun until the pinkness subsides.

10. STAY OUT OF DIRECT SUN UNTIL THE AREAS HAVE COMPLETELY HEALED. (3-6 months)

11. Are you prone to Keloids? Yes

Ihave read and understand the contents of this consent.